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Imaging and laboratory workup for hand infections. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic, Therapeutic Topic : Fingertip infections - Diagnostic tests This is a narrative review on epidemiology and treatment of fingertip infections. Finger tip infections included acute and chronic paronychia, felon, and infection mimickers. Acute paronychia often affect the middle 3 digits and should be differentiated from herpetic whitlow. If the condition does not resolve within a few days, oral antibiotics or antibiotic creams should be prescribed. Chronic paronychia is defined as an inflammation of the nail fold that lastes longer than 6 weeks. This condition is not as severe as an acute paronychia and it often develops due to on-going mechanical or chemical insults (e.g. swimmers, homemakers) following an acute paronchia. Felon is an infection of the finger pulp and it represent 15-20% of all the hand infections. These infections are often reported after fingerprick testing for diabetes or splinters' punctures. Felons can be treated conservatively through antibiotics or surgically with incfection evacuation. If not treated appropriately, they may result in osteomylietis, flexor tenosynovitis, and potentially tendon rupture. Mimickers of paronychia or felons include calcific tendinitis, gout, herpetic whitlow, cancer, rheumatologic conditions, and zoonoses. Calcific tendinitis can be easily identified through x-rays and responds well to anti-inflammatories and corticosteroids. Gout may be identified through bony erosions evident on x-ray and it can affect the dipj. Herpetic whitlow is a herpes simplex infection which is extremely contagious during the first two week. The use of gloves by the clinician significantly reduce the risk of them contracting the condition. Oral acyclovir should be prescribed. Cancer can mimick paronychia and treatment depends on the type of malignancy. Rheumatologic conditions such as psoriasis and reactive arthritis may cause nail changes and are usually associated with systemic issues (e.g. conjunctivitis, urethritis). Zoonoses are other fingertip infections which are transferred from vertebrate animals to humans (remember the word "zoo"). Zoonoses require close follow up as they may require hospital admission. Clinical Take Home Message : Hand therapists should monitor patients with a suspected fingertip infection closely. If the condition is not responsive to antibiotics or surgical evacuation an infection mimicker should be considered as a differential diagnosis. The most common mimickers appear to be gout and herpetic whitlow. A thorough subjective examination, including client's occupation, may aid in the diagnosis. URL : https://www.clinicalkey.com.au/#!/content/1-s2.0-S0749071220300317

Imaging and laboratory workup for hand infections. Whitaker, C. M., Low, S., Gorbachova, T., Raphael, J. S., & Williamson, C. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : Hand infections - Diagnostic tests This is a narrative review on diagnostics for of hand infections. The hand infections included abscesses, cellulitis, septic arthritis, pyogenic tenosynovitis, osteomyelitis, and necrotising fasciitis. X-rays are useful in identifying focal bone erosion, cortical changes, and associated fractures in infections. In addition, they can be useful in excluding differential diagnoses for infections such as gout or calcific tendinitis. US imaging is also useful in identifying non radiopaque foreign bodies. Abscesses often present as soft tissues mass on x-rays associated with an hypoechoic (dark appearance) collection of fluid and increased vascularity on US (US is 97% sensitive for this condition, meaning that a negative finding can exclude this diagnosis). Cellulitis often presents with an increase in subcutaneus edema on x-rays and US, which is common to other conditions and requires clinical confirmation. Septic arthritis consists in an infection limited to the articular joint. X-rays and US are not particularly useful in the initial stages even though they may identify capsular distension. Pyogenic tenosynovitis is an infection of the flexor tendon sheet. Unfortunately, x-rays and US are not often useful in confirming the diagnosis, although they can exclude the presence of a foreign body. Osteomyelitis is an infection of the bone marrow and bone. X-rays are usually negative for 1-3 weeks since onset and US are not useful in identifying this condition. Necrotising fascitis is a potentially fatal infection of the soft tissue which is not easily diagnosed through x-rays or US in the initial stages of the condition. Emergency care is required for this condition. Clinical Take Home Message : Hand therapists should refer patients for x-rays and US when they suspect an infection. These investigations are useful in identifying the presence of foreign bodies and exclude other conditions (e.g. gout, calcific tendinitis), which may mimic infection presentations. Signs of osteomyelitis are not evident on x-ray until 1-3 weeks since onset and x-rays may be repeated to exclude this condition. A prompt referral to ED or hand surgeon may be required. URL : https://www.clinicalkey.com/#!/content/1-s2.0-S0749071220300299

Hand Infections: Epidemiology and Public Health Burden. Gundlach, B. K., Sasor, S. E., & Chung, K. C. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Aetiologic, Diagnostic, Therapeutic Topic : Hand infections - Epidemiology This is a narrative review on epidemiology, risk factors, diagnosis, and treatment of hand infections. The frequency of hand infections is two times greater in men compared to women, with more than 30% of infections caused by trauma. Animal bites account for a large proportion of hand infections. Hand surgery rarely leads to hand infections (0.17%). Close to 50% of hand infections are caused by staphylococcus aureus. Risk factors for hand infections include diabetes, HIV infection, immunosuppression, and intravenous drug use. In addition, being an horticulturist, fisherman, aquarist, veterinarian, or dentists increases the chances of presenting with a hand infection. The mechanism of injury, symptoms duration as well as hobbies and occupation may help with the diagnosis. Tetanus vaccination may be required following any bite injury or open skin trauma. Patients with hand infections often do not present with fevers or chills and laboratory testing is often normal in the initial stage of infections. Rapid changes in the clinical presentation and pain beyond what is reasonable expected, should hint towards the presence of an infection. The use of radiographs may help exclude the presence of a foreign body or a fracture. Mobilisation of the hand should start as soon as possible and the use of slings avoided. Clinical Take Home Message : Hand therapists should be aware that diabetes and animal bites are risk factors for hand infection. This information is supported by previous evidence as well as one of our synopsis . In addition, occupations where there is close contact with animals or plants (e.g. vets, gardeners/horticulturists) appear to expose people to greater risk of hand infections. URL : https://www.clinicalkey.com/#!/content/1-s2.0-S0749071220300287

Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome. Coppieters, M. W., & Alshami, A. M. (2007) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Nerve gliding - Median nerve This is an experimental study assessing median nerve excursion and strain with different exercises in cadavers. Six cadavers' arms were prepared for this study. To measure strain, two displacement tansducers were applied to the median nerve just proximally to the wrist at 12cm proximal to the medial condile of the humerus. To measure excursion, a high precision caliper assessed displacement of the median nerve at the wrist and at the humerus. The median nerve strain and excursion was measured under six different conditions. These included a median glider (wrist flexion-elbow extension and vice versa), median tensioner (wrist and elbow extension and vice versa), wrist motion (extension-neutral) in elbow extension or flexion, elbow motion (flexion-extension) with wrist in extension or neutral. The study needs to be considered in the context of a few limitations. The experiment was performed in cadavers and in vivo studies may show different results. The cadavers did not have a history of carpal tunnel syndrome, which may change the ability of the median nerve to glide within the carpal tunnel. The results showed that there was a statistically significant greater excursion (nerves usually like excursion or gliding but not straining) of the median nerve during the median glider exercise (wrist flexion-elbow extension and vice versa) compared to all the other exercises. The absolute excursion for the glider exercise ranged betweeen 3 to 9 mm which may be clinically relevant. The median nerve strain was statistically significant higher (the median nerve was under greater tension) in the exercises combining wrist and elbow extension in any order compared to the other exercises. The strain increased by 2% with these exercises. Interestingly, the overall strain never exceded 4% of the initial length (6% of strain may be deleterius if held for a prolonged period of time - see Wall et al. 1992 ). Clinical Take Home Message : Median nerve gliders appear to be safe for use in carpal tunnel syndrome. Hand therapists may avoid combining wrist and elbow extension exercises, which have been shown to to reduce nerve excursion and increase nerve strain. Median nerve gliding exercises do not appear to reduce symptoms in people with carpal tunnel syndrome when added to a splinting regime. However, they may be used in patient prone to develop stiffness. Open Access : https://onlinelibrary.wiley.com/doi/epdf/10.1002/jor.20310

Overuse syndrome of the hand and wrist in musicians: a systematic review. Betzl, J., Kraneburg, U., & Megerle, K. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Aetiology, Preventative, Therapeutic Topic : Musicians – Overuse syndromes This is a systematic review on epidemiology, pathophysiology, symptoms, and treatment of overuse syndromes in the upper limb of musicians. Forty-two studies were included for a total of more than 1300 musicians. The methodology of the studies varied significantly with a combination of case studies, retrospective studies, and prospective studies. Overuse syndrome was defined as a specific or non-specific painful condition which was aggravated by playing an instrument. The results indicated that the point prevalence for overused syndrome (prevalence measured at one time point) in musicians ranges between 40% to 50%. The lifetime prevalence for overuse syndrome (percentage of musicians who will experience an overuse syndrome at some point in their lifespan) in musicians ranges between 70% to 90%. Very limited research assessed the pathophysiology of overuse syndromes in musicians, with results showing muscle fibre changes as well as local muscle edema in participants with pain compared to controls. Symptoms may be present during practice and at rest. Forced rest appears to be useful in a small subgroup of patients only. An individualised rehabilitation plan with a biopsychosocial approach appears to be more effective in a greater number of musicians. This biopsychosocial approach includes mind-body interventions (e.g. yoga, mindfulness) as well as physical treatments aiming at increasing the general level of fitness of musicians. Clinical Take Home Message : Hand therapists may take a biopsychosocial approach in the treatment of muscians with overuse syndrome. Forced rest does not appear to be a very effective approach. Increasing the overall fitness of musicians and reducing stress may be helpful in reducing pain associated with overuse syndromes of the hand. URL : https://journals.sagepub.com/doi/10.1177/1753193420912644

Mindful body scans and sonographic biofeedback as preparatory activities to address patient psychological states in hand therapy: A pilot study. Roll, S. C., Hardison, M. E., Vigen, C., & Black, D. S. (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Mindfulness - Pain and anxiety This is a randomised crossed-over single-blind control trial assessing the effectiveness of mindfulness body scan, sonographic biofeedback, and standard care on pain and anxiety in paticipants attending hand therapy sessions. Participants (N=19) were included if they were referred for hand therapy and if they presented with unilateral hand pathology. Participants were excluded if they were in a cast, if they presented with openn wounds, or if they attended hand therapy less than twice a week. Pain was assessed through the visual analogue scale (VAS), and anxiety was measured through the state-trait anxiety inventory (STAI). All the measurements were taken immediately before and after the hand therapy sessions. After inclusion in the study, participants were allocated to standard care for the first visit and subsequently randomised to either mindfulness body scan (n=10) or Biofeedback (n=10). They were then crossed over to the other group in the following two sessions. Standard care, which was provided at the first appointment, included an assessment and treatment selected by the treating hand therapist. The mindfulness body scan was delivered for 20 minutes through an audio-guided meditation. The sonographic biofeedback provided participants with an understanding of tendon movements within the affected and unaffected hand before therapy. Participants in the biofeedback group were also asked to think about their tendons gliding during the hand therapy treatment. The results showed that all the interventions reduced pain and anxiety, although the changes were not clinically relevant. There were no statistically or clinically significant differences in pain or anxiety between the experimental groups (Mindfulness and biofeedback) and the standard care group. It is possible that this study was underpowered to identify any difference between groups. The washout period for the cross-over was short (2-3 days) and it is possible that the carryover effect of standard care or mind-body intervention was still present when the assessment was taking place. Clinical Take Home Message : Hand therapists should not expect a change in pain or anxiety in patients undergoing a brief mindfulness practice or biofeedback intervention. A 10 weeks mindfulnes-based stress reduction program may be required to induce clinically and statistically significant changes in pain and anxiety in selected patients presenting with significant anxiety. URL : https://journals.sagepub.com/doi/abs/10.1177/1758998320930752

The influence of a positive empathetic interaction on conditioned pain modulation and manipulation induced analgesia in people with lateral epicondylalgia. Muhsen, A., Moss, P., Gibson, W., Walker, B., Jacques, A., Schug, S., & Wright, A. (2020) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia - Emphatic vs neutral interaction This is a randomised double-blind placebo controlled trial assessing the effect of empathy alone vs empathy and cervical mobilisations on endogenous analgesia and pain-free grip strength in participants with lateral epicondilalgia (LE). Participants (N = 68) were diagnosed with LE if they presented with pain on passive stretching of the wrist extensors, resisted contraction of the wrist and finger extensor, and experienced pain at the lateral epicondyle during palpation. If the clinical picture suggested the presence of any other pathology (e.g. cervical radiculopathy, other chronic pain conditions, or history of surgery/fracture in upper limb), participants were excluded. Endogenous analgesia was tested by assessing pain pressure thresholds at the elbow. Participants' pain-free grip strength was assessed on the pathological side only. The effect of empathy (n = 34) vs neutral interaction (n = 34) was measured both in isolation (at Time 1) or in combination with cervical lateral glides (at Time 2). In the empathic group, the interaction between research assistant and participants was supportive, positive, and friendly. For the neutral interaction, the research assistant did not pay much attention to the participants except for explaining the procedure associated with the testing and treatment. The results showed that the effect of an empathic interaction alone, improved endogenous analgesia by 13.5%, which almost doubled with the addition of cervical mobilisation to 25%. The effect of cervical mobilisations alone, without the adjunct of an emphatic interaction, improved endogenous analgesia by 9% from baseline. No differences in pain-free grip strength were noticed between groups. Clinical Take Home Message : A positive therapeutic interaction significantly improves the engodenous pain relieving abilities of patients with lateral epicondylalgia in the short term. When combined with cervical mobilisations, it appears that this effect is boosted. Empathetic bedside manners are a potent ally in patient care. URL : https://journals.lww.com/clinicalpain/Abstract/9000/The_Influence_of_a_Positive_Empathetic_Interaction.98726.aspx

Nonsurgical treatment of De Quervain tenosynovitis: a prospective randomized trial. Ippolito, J. A., Hauser, S., Patel, J., Vosbikian, M., & Ahmed, I. (2018) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : De Quervain tenosynovitis - Conservative management This is a randomised controlled trial assessing the effectiveness of immobilisation following cortisone injection in participants with De Quervain tenosynovitis. Participants (N = 20) were diagnosed with De Quervain if they had pain on the radial side of the wrist, pain greater than 4/10 (VAS), positive Finkelstein test, tenderness on palpation at the first dorsal compartment of the wrist. Participants were excluded if they had a previous cortisone injection within the last 6 months, carpal tunnel syndrome, radiculopathy, or previous infection at the treatment site. Effectiveness of treatment was assessed through the VAS for pain anf the DASH score for function. These outcomes were assessed before treatment, at 3 weeks post treatment, and at 6 months post treatment. Participants and assessors were not blinded to treatment allocation. Participants were randomised to a cortisone injection only (n = 9) or a cortisone injection and splinting for 3 weeks (n = 11). Participants in both groups were advised to rest and limit exercise as much as possible for three weeks. The results showed no difference between the two groups on pain or function at 3 and 6 months. Clinical Take Home Message : Hand therapists should advise their patients to rest their hand as much as possible for 3 weeks following a cortison injection for De Quervain tenosynovitis. Immobilisation does not appear to add any benefit in terms of pain and function at short and long term follow-up. URL : https://journals.sagepub.com/doi/full/10.1177/1558944718791187

A systematic review of musculoskeletal disorders related to mobile phone usage. Zirek, E., Mustafaoglu, R., Yasaci, Z., & Griffiths, M. D. (2020) Level of Evidence : 3a Follow recommendation : 👍 Type of study : Symptoms prevalence study Topic : Mobile phone use - Association with MSK pain This is a systematic review assessing the effect of mobile phones on musculoskeletal (MSK) pain conditions. Eighteen studies were included for a total of 36,243 participants. Of these, 15 were cross-sectional studies, 2 were case-control studies, and 1 was a prospective cohort study. The Scottish Intercollegiate Guidelines Network (SIGN) checklist was utilised to assess study quality. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which is suggested by the Cochrane group for systematic reviews. The results show that there was overall a low and very low quality of evidence supporting the findings of this review. The prevalence of MSK pain was 19% to 53% in the thumb, 15% in the elbow, and 13% to 32% in the wrist and hand. One of the limitations of this review was that the prevalence of MSK pain in people not using mobile technology was not reported. In addition, most of the studies reported correlations between mobile technology use and MSK pain. Correlation does not equate to causation and there may be other factors (e.g. amount of physical activity, mental helath) that contribute to these pain presentations. Clinical Take Home Message : Hand therapists should not advise their patients against the use of mobile technology to avoid MSK pain conditions. Instead, hand therapists may invite patients to be physically active and vary their movements and physical activity during the day. URL : https://www.sciencedirect.com/science/article/abs/pii/S2468781220300114

What is the incidence of complex regional pain syndrome (CRPS) Type I within four months of a wrist fracture in the adult population? A systematic review. Rolls, C., McCabe, C., Llewellyn, A., & Jones, G. T. (2020) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Prognostic Topic : CRPS I - Incidence after wrist fracture This is a systematic review assessing the incidence of complex regional pain syndrom (CRPS) following a wrist fracture. Nine prospective cohort trials were included for a total of 2465 participants. Studies were only included if CRPS type I (no nerve damage) was assessed. All papers included were scored on the Newcastle-Ottowa Scale for cohort study (0 lowest score, 6 highest score). The diagnosis of CRPS was made through the Budapest Criteria in most studies (n=6). Incidence of CRPS was assessed at 4 months post wrist fracture. Data were extracted from the highest quality studies only (n=3). Wrist fractures included distal radius fractures, ulnar fractures, and carpal fractures (e.g. scaphoid). The pooled results showed that 7% (95%CI: 2% to 13%) of participants with a distal radius fracture developed CRPS type I at 4 months (An incidence meta-analysis was completed for this synopsis as the authors of the study only provided a range). Of interest, one of the studies with the greatest sample size (n=1506), identified pain greater than 5/10 within the first week after trauma as a prognostic factor for the development of CRPS. Clinical Take Home Message : Hand therapists should be aware of the possibility of CRPS type I following wrist fracture. The condition appears to develop in 1 person out of 20 at four months after injury. Moderate to high levels of pain in the first week after trauma may predispose to the development of CRPS type I. URL : https://journals.sagepub.com/doi/abs/10.1177/1758998320910179

The effectiveness of physical therapies for patients with base of thumb osteoarthritis: Systematic review and meta-analysis. Ahern, M., Skyllas, J., Wajon, A., & Hush, J. (2018) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Thumb OA – Unimodal and multimodal treatments This is a systematic review and meta-analysis assessing the effectiveness of unimodal and multimodal treatments for symptomatic thumb osteoarthritis (OA) on pain and function. Five randomised controlled trials were included for a total of 198 participants. All the studies included were assessed through the risk of bias tool suggested by the Cochrane review group (higher scores reflect higher study quality). The active treatments for the studies included varied from mobilisation of the 1st cmcj and surrounding tissues (exercises, neurodynamic exercises, manual therapy) to splinting for the 1st cmcj. Pain was assessed at rest or after pinching through a visual analogue scale (0 to 10). Function was measured through the QuickDASH and the AUSCAN questionnaires. The results showed that four studies scored 5/6 on the study quality score (high quality studies), while one study scored 4/6 (moderate quality study). Pain improved to a clinically and statistically significant level in both multimodal (mean difference 2.9: 95%CI: 2.8 to 3) and unimodal interventions (mean difference 3.1: 95%CI: 2.5 to 3.8) when compared to either a control group or sham treatment. Function improved to a statistically but not to a clinically significant level in the unimodal intervention (mean difference 6.8: 95%CI: 1.7 to 11.9) compared to the control group or sham intervention (no function was reported for multimodal interventions). Clinical Take Home Message : Hand therapists may use manual therapy, exercise, neurodynamic exercise, or splinting to reduce pain for 1st cmcj OA. These interventions do not appear to improve function to a clinically relevant level. URL : https://www.sciencedirect.com/science/article/abs/pii/S2468781218300456

Effects of yoga on depressive symptoms in people with mental disorders: a systematic review and meta-analysis. Brinsley, J., Schuch, F., Lederman, O., Girard, D., Smout, M., Immink, M. A., Stubbs, B., Firth, J., Davison, K., & Rosenbaum, S. (2020) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Depression - Yoga vs treatment as usual This is a systematic review and meta-analysis assessing the effectiveness of yoga on depressive symptoms. Thirteen randomised controlled trials were included for a total of 1080 participants. Studies were included if at least 50% of each yoga session included a movement component - the rest of the yoga session could include breathing control exercises, or mindfulness. The control group underwent either standard care, or were put on a waitlist. The effectiveness of the interventions was assessed by measuring changes in depressive symptoms. Out of the studies included, nine studies included participants with depressive disorders, five included participants with schizophrenia and depression, three included participants with post-traumatic stress disorder and depression, one included participants with substance dependence and depression, and another one included participants with a mix of mental health conditions and depression. The frequency of yoga sessions varied from 1-3 sessions per week with a variable duration between 20-90 minutes. Out of all the studies included, 53% were of high quality and 47% were of fair quality (PEDro scale). The results showed that yoga had a moderate effect (Standardised mean difference=−0.41; 95%CI −0.65 to -0.17) in reducing depressive symptoms compared to all the control groups. The effectiveness of yoga was correlated with the number of sessions attended each weak, with higher number of sessions attended resulting in greater reduction of depressive symptoms. The remission rates (number of participants who were no longer diagnosed as depressed after the intervention) ranged between 39% to 60% in the yoga group compared 10% to 24% in the control group. This difference was statistically significant. No adverse events were reported. Clinical Take Home Message : Hand therapists may suggest the attendance of yoga classes to patients presenting with depressive symptoms. Considering the relationship between depressive symptoms and upper limb recovery as well as mental health and post surgical satisfaction in CTS , it may be worthwile to help patients improving their depressive symptoms. URL : https://bjsm.bmj.com/content/early/2020/04/05/bjsports-2019-101242